Foreign body ingestion

Foreign body (FB) ingestion is a potentially life-threatening condition that occurs most commonly in children aged 6–36 months. While some FB will typically pass the GI tract spontaneously without complications (e.g., small marbles), others (e.g., batteries, multiple magnets, and sharp objects) can cause severe damage or obstruction of the GI tract and should always be considered an emergency. In most cases, the diagnosis will be based on the patient report or the report of a witness (e.g., parent), but in some cases, the diagnosis is only confirmed on imaging. Imaging is also required to determine the type of FB and its location within the GI tract; in this context, it is vital to distinguish button batteries from objects of similar shape (e.g., coins) on x-ray, as battery ingestion requires immediate endoscopic removal to avoid caustic injuries. Endoscopic removal is likewise indicated in the ingestion of multiple magnets (multiple magnets pose a high risk of intestinal obstruction, perforation, and ischemia due to entrapment of intestinal loops between magnets), sharp objects, and any other object causing significant symptoms of GI tract obstruction or failing to pass spontaneously (e.g., coin located in the stomach for > 4 weeks).

Epidemiology ^[1]

• Children and infants
  • Peak incidence: 6–36 months
  • Approx. 80% of FB ingestion cases occur in pediatric patients.

• Adult
  • Less common (adults account for approx. 20% of all FB ingestion cases)
  • Prevalence highest in the prison population and in individuals with psychiatric conditions

Etiology

• Children and infants
  • Accidental ingestion of a FB
    • Coins (most commonly ingested FB)
    • Button batteries
    • Toy parts
    • Small magnets from toys and household appliances
    • Sharp objects (e.g., pins, paperclips, fish bones)
  • Toddlers are prone to examining objects with their mouths.
• Adults
  • Accidental ingestion (e.g., of small bones with a meal)
  • Intentional FB ingestion may have psychiatric causes or may be criminally motivated (e.g., drug smuggling).

Clinical features by localization of FB

• Esophagus
  • Dysphagia
  • Drooling
  • Refusal to eat
  • Retrosternal pain
  • Respiratory symptoms (e.g., wheezing, choking)
  • Signs of esophageal perforation (e.g., pneumomediastinum, crepitus in the suprasternal notch and neck region)
• Stomach
  • Small FB are often asymptomatic
  • Nausea, vomiting
  • Refusal to eat
• Intestine
  • Usually asymptomatic
  • Late complications (chronic inflammation, perforation) can occur if the FB is retained

Diagnostics

• Patient history: careful history to elicit the type and number of FB ingested
• Physical examination
  • Chest examination to rule out esophageal perforation
  • Abdominal examination to assess for bowel obstruction or perforation
• Imaging
  • X-ray of the neck, chest, and abdomen (AP and lateral view)
    • Identify the location and dimensions of radiopaque FB (e.g., metal objects)
    • Indirect signs of radiolucent FB (e.g., plastic, wood, fish bones): air-fluid levels
    • Free air indicates perforation
  • CT: indicated in symptomatic patients, if the FB poses a risk for complications (sharp objects, large FB ) or x-ray was inconclusive
  • MRI
    • Indicated to visualize radiolucent FB and assess surrounding tissue
    • Contraindicated if a metallic FB is suspected or the type of FB is unknown.

Management of foreign body ingestion ^[2][3]

• General: Prioritize airway management and stabilization over diagnostics if there are any signs of respiratory distress or gastrointestinal perforation.
• Expectant management (80–90% of cases): in asymptomatic patients with a small, blunt FB (e.g., coin) located either in the esophagus for < 24 hours or in the stomach/intestine
• Endoscopy (10–20% of cases): flexible or rigid endoscopy
  • Emergency endoscopy (< 2 hours of ingestion)
    • Any FB that causes severe symptoms (e.g., respiratory distress, difficulty swallowing)
    • Button battery lodged in the esophagus
    • Multiple magnets located in the esophagus or stomach that cause symptoms
    • Sharp objects in the esophagus with suspected obstruction/perforation (e.g., pain, vomiting, fever, hematemesis)
  • Urgent endoscopy (< 24 hours of ingestion)
    • Any FB that causes symptoms
    • FB lodged in the esophagus for > 24 hours
    • Large (> 20 mm) button battery or any size button battery in patients < 5 years of age that is located in the stomach/duodenal bulb and does not cause symptoms
    • Magnets or sharp objects located in the stomach/duodenal bulb
  • Elective endoscopy: failed expectant management (FB is retained in the stomach for > 4 weeks)
• Surgery (1% of cases)
  • Any type of FB located in the intestine with signs of intestinal obstruction or perforation
  • Multiple magnets or sharp objects lodged in the intestine (symptomatic or absent progression on serial radiographs)
  • Unsuccessful endoscopic removal of a FB

80–90% of foreign bodies ingested by children are passed spontaneously.

• Pathophysiology
  • Depends on the type and dimensions of the FB
  • Ingested small FB typically pass through the GI tract spontaneously.
  • Mucosal injury and acute inflammation may occur (e.g., sharp edge, toxic or irritant material).
• Clinical features
  • Often asymptomatic
  • Transient chest discomfort and dysphagia as the FB progresses through the esophagus
  • Drooling, difficulty swallowing, and retrosternal pain may indicate esophageal impaction.
  • FB located in the stomach and intestine are usually asymptomatic.
• Diagnostics
  • Ingestion is typically either self-reported or reported by a third person (e.g., parent) who witnessed or suspected ingestion.
  • Radiographs: findings depend on the type and radiopacity of the FB
  • It is important to distinguish between coins and button batteries on x-ray (see distinguishing features in “Ingestion of button batteries”).
• Management ^[2][3]
  • Expectant management
    • Patients with a small, blunt FB (e.g., coin) located in the esophagus for < 24 hours without severe symptoms
    • Asymptomatic patients with a small, blunt FB located in the stomach or intestine
  • Emergency endoscopy (< 2 hours): indicated in any type of FB lodged in the esophagus causing severe respiratory symptoms, drooling, and/or difficulty swallowing.
  • Urgent endoscopy (< 24 hours): indicated in case of coin lodged in the esophagus that was ingested > 24 hours ago or unknown time of ingestion
  • Elective endoscopy: indicated in case of coin retained in the stomach/duodenal bulb for > 4 weeks
  • Surgery: indicated in case of coin retained in the intestine for > 4 weeks
• Complications
  • Rare
  • Usually resolves spontaneously

• Pathophysiology
  • Button batteries lodged in the moist environment of the esophagus can cause a caustic injury: electrolytic reaction, leading to the formation of hydroxide radicals, which cause corrosion and tissue necrosis
  • Serious burns may result within 2 hours of ingestion.
  • High risk of caustic injury to adjacent structures (e.g., trachea, aortic arch)
  • Caustic injury most commonly occurs in the esophagus; incidence of esophageal injury is highest in young children (due to smaller esophagus) and individuals with a history of esophageal disease.
• Clinical features
  • Possibly asymptomatic
  • Drooling, vomiting
  • Chest discomfort, dysphagia
  • Mediastinitis
  • Esophageal perforation
• Diagnostics
  • History of witnessed or self-reported ingestion
  • X-ray
    • AP view: Halo/double-rim effect
    • Lateral view: button batteries show a step-off effect due to the different size of the negative (smaller) and positive pole
• Management ^[2][3]
  • Emergency endoscopy (< 2 hours) is indicated in case:
    • Button batteries lodged in the esophagus
    • Button batteries located in the stomach/duodenal bulb if the patient is symptomatic
  • Urgent endoscopy (< 24 hours) is indicated in case of:
    • Button battery located in the stomach/duodenal bulb in asymptomatic patients if
      • Age < 5 years, and/or size of the battery > 20 mm
      • Suspected coingestion of magnet
  • Surgery is indicated in the following situations:
    • Esophageal impaction in a clinically unstable patient
    • Failed endoscopic removal
• Complications
  • Tracheoesophageal fistula
  • Esophageal perforation
  • Esophageal strictures
  • Mediastinitis
  • Vocal cord paralysis (recurrent laryngeal nerve injury)

Always consider the possibility that a button battery in children presenting with foreign body ingestion, esp. if parents report the ingestion of coins or similarly shaped objects.

Button batteries lodged in the esophagus can cause significant injury within hours of ingestion and should be removed immediately.

References:^[4]

• Pathophysiology
  • Ingestion of a single magnet is usually unproblematic; high-powered magnets may, however, attract to external metal objects (e.g., trouser buttons, belt buckles)
  • Ingestion of multiple high-powered magnets or a single high-powered magnet plus a metal object can cause obstruction, perforation, and ischemia due to entrapment of intestinal loops between magnets.
• Clinical features
  • Possibly asymptomatic
  • Abdominal pain
  • Signs of bowel ischemia or bowel perforation
• Diagnostics
  • History of witnessed or self-reported ingestion
  • Abdominal x-ray
    • Batteries are radiopaque
    • Stacked magnets with narrow space between them suggest bowel wall entrapment
• Management ^[2][3]
  • Magnets located in esophagus or stomach: prompt endoscopic removal
  • Magnets located in the intestines
    • Symptomatic patients: surgical removal
    • Asymptomatic patients: monitor with serial imaging (4–6 hours intervals)
• Complications
  • Intestinal pressure necrosis
  • Intestinal fistula
  • Volvulus
  • Perforation
  • Obstruction

• Commonly ingested sharp objects
  • Chicken bones
  • Fish bones
  • Straight pins
  • Paperclips
  • Open safety pins
  • Toothpicks
• Pathophysiology
  • High risk of mucosal injury and perforation of the gastrointestinal tract
• Clinical features
  • Immediate symptoms following ingestion: choking, drooling, cyanosis, inability to swallow, retrosternal pain
  • Esophageal perforation: swelling, subcutaneous crepitus
• Diagnostics
  • History of witnessed or self-reported ingestion
  • X-ray
    • Most metal objects are radiopaque
    • Radiolucent objects include plastic parts, wooden toothpicks, some fish bones
  • CT scan: to identify radiolucent or small FBs not detected on x-ray and assess surrounding tissue
• Management ^[2][3]
  • Emergency endoscopic removal (< 2 hours) is indicated if the sharp object located in the esophagus or the stomach with signs of obstruction or perforation
  • Urgent endoscopy removal (< 24 hours) is indicated if the sharp object is located in the esophagus (without severe symptoms) or in the stomach/duodenal bulb in asymptomatic patients
• Complications
  • Esophageal perforation
  • Gastric perforation